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REQUESTER & PASSENGER

Who is arranging this ride?

Your selection determines the contact details we need.

Who is completing this request? *

PassengerFamily or caregiverFacility

Passenger contact information

First name *Last name *

Phone number *Email address *

♿ Mobility and assistance

Mobility type *

Assistance level *

Curb-to-curbPassenger can reach and leave the vehicle independently.Door-to-doorDriver assists between the vehicle and exterior door.Door-through-doorPassenger needs additional assistance inside.

Stairs at pickup or destination?Will an escort ride?

Mobility or access notes

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TRIP

Where and when?

Add the trip details. Requests should be made at least 3 days in advance when possible.

Trip type *

One way Round trip

Date of service *Date format: MM/DD/YYYY

Requested pickup time *

Appointment or required arrival time *

Pickup address *Pickup instructions

Destination name *Destination address *Destination details

Return pickup

Scheduled time Will call

Requested return pickup time *

Does this trip repeat?Set up recurring or standing-order details.

Yes, this trip repeats

Trip notes

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BILLING

How will the trip be paid?

Select the option that applies to this request.

▣Private payPayment is due before the service date.▣MassHealthRequires an approved PT-1 and MART scheduling.▣Facility accountFor authorized facility or contract billing.

Private-pay details

Payer name *Payer phone *

Payer email * I understand payment must be received before the service date and an unpaid trip may be cancelled 24 hours before service.

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Cancellation policy
Cancel at least 24 hours in advance for a full refund. Later cancellations receive a 50% refund, subject to confirmation by our team.

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REVIEW

Check the request.

Nothing is booked until Go Time confirms availability.

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REQUEST STATUSAwaiting review

Not booked

PICKUPPickup address not enteredDate not entered · Pickup time pending

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DESTINATIONDestination name not enteredDestination address not entered

Requester & passenger

Trip

Billing

Complete this security check before sending.

Who is arranging this ride?

Passenger contact information

Family or caregiver contact

Passenger information

Facility requester